Heparin in AMI

[Soul]

I have one question regarding management of AMI.

For how long do you use heparin (UFH or LMWH) in a pt with non-STEMI? as well for for a pt with STEMI who is receiving streptokinase or urokinase or tPA or who udergone PCI (before and after the procedure)? Plz share ur knowledge ...thanx in advance.

[rajupangeni]

thats a million dollar question, soul.. its not easy to answer coz even if we do, its going to change after 6 months..! there are hundreds of trials going on every year in cardiology and plenty of new changes in guidelines..

recent guidelines recommend UFH or LMWH heparin for all cases of NSTEMI ranging from 48 hours to 6 days, or till angiography.. studies havent shown of beneficial effect if given for less than 48 hrs or for more than 8 days.. we normally use enoxaparin s/c for 6 days in our hospital..

heparin is not recommended if fibrin nonspecific thrombolytics are used, like streptokinase, for the possible risk of bleeding.. but its use has been recommended during and for at least 24 hours after the use of recent fibrin specific fibrinolytics like alteplase, reteplase and tenecteplase.. we donot usually use heparin after streptokinase, though recent trials have shown positive benefit/risk ratio (its all about what trials say!) unfortunately, fibrin specific agents are too expensive and they are not available easily in Nepal..

its also used along with aspirin, clopid and GPIIb/IIIa inhibitors like abciximab for patients undergoing PCI.. LMWH is used if CABG is planned after 24 hrs, or else intravenous heparin is used which can be stopped shortly before the procedure, LMWH are given subcut so have prolonged duration of action.. i dont have much knowledge regarding the protocol of heparin therapy during these invasive procedures..

i am sure we'll be using some more specific pentasaccharide factor Xa inhibitors like fondaparinux, along with tenecteplase (recent guidelines have already started to include them) after some years here in our country itself..

fens, waiting for some more views...

[Soul]

Thanx rajupangeni for this superb info....

Ya its true that heparin is not given when streptokinase is used as a fibrinolytic, but it is reasonable to give concomitant heparin if risk of DVT, PE is high, if the pt had prevly developed such conditions. however it increases the risk of major bleeding, so guideline also doesn't support routine use of heparin with streptokinase.

LMWH (enoxaparin) has been recently approved by FDA for use in STEMI. Might be due to the results of exTRACT-TIMI 25. Though LMWH increases the risk of major bleeding, the net clinical benefit (death, non fatal MI) is superior to UFH.

PCI has become the 'therapy of choice' in STEMI, and I also believe that PCI is more cost-effective than fibrinolytics in STEMI. Fibrinolytics are RARELY used in our hosp, so I was curious to know the protocol at other hosp. Thanx again for such a valuable info.